RADIOLOGICAL VIGNETTE
Reumatismo 4/2017 189
Plantar pain is not always fasciitis
N. Romano1, A. Fischetti1, V. Prono1, S. Migone1, F. Barbieri2, C. Pizzorni2, G. Garlaschi1, M.A. Cimmino2
1Division of Radiology, and 2Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy
SUMMARY
The case is described of a patient with chronic plantar pain, diagnosed as fasciitis, which was not improved by conventional treatment. Magnetic resonance imaging revealed flexor hallucis longus tenosynovitis, which improved after local glucocorticoid injection.
Key words: Plantar pain; Fasciitis; Tenosynovitis; Flexor hallucis longus.
Reumatismo, 2017; 69 (4): 189-190
n RADIOLOGICAL VIGNETTE
Plantar pain is a frequent musculoskel- etal problem. It is usually due to plantar fasciitis, a condition affecting 3.6% of the general population (1). When pain persists in spite of conservative treatment and rest, the cause could be inflammatory because enthesitis is a common manifestation of seronegative spondyloarthritides (2). Alter- natively, pain could be caused by involve- ment of a different structure. We report a patient treated for one year for plantar fas- ciitis, who was affected by flexor hallucis longus (FHL) tenosynovitis diagnosed by magnetic resonance imaging (MRI).
A 50-year-old man presented with a one- year history of severe pain on the medial side of the sole of the feet that was more intense in the right foot. Pain intensity on a 100 mm visual analogue scale was 60 mm.
His medical history was unremarkable ex- cept for dyslipidemia and previous rupture of the left Achilles tendon. He had been an active sportsman, who practiced jogging and climbing. Conventional radiography showed one entesophyte of the right calca- neum. Plantar fasciitis was diagnosed and he was treated with rest, NSAIDs, local in- jections of platelet rich plasma and physio- therapy without efficacy.
At physical examination in the rheumatol- ogy outpatient clinic, tenderness was pres- ent at pressure of the sole of the feet. This
was more intense on the right side. The cal- caneal insertion of the fascia was not ten- der. Pain was not elicited at extension and flexion of the great toe.
An MRI exam was performed on a dedi- cated 0.3 T unit (Oscan, Esaote, Genova, Italy) with T1-weighted spin echo, STIR and 3DT1 sequences on the three planes of the space. Increased thickness (6 mm) of the medial band of the plantar fascia with- out signs of inflammation was seen in the sagittal plane. It was associated with slight edema of the adipose subcutaneous tis- sues. Fluid was seen surrounding the FHL tendon, a finding suggesting tenosynovitis (Figure 1a). In the axial plane, FHL teno- synovitis was demonstrated up to the level of the first cuneiform. No bone edema was observed. The other tendons and ligaments were normal (Figure 2a and b).
The patient was treated with deep periten- dineous injection of long-acting glucocor- ticoids through a plantar approach. The needle was inserted based on the measure- ments obtained from the MRI images. Af- ter five weeks, pain intensity was decreased to 20 mm and a new MRI showed almost complete disappearance of tenosynovitis (Figures 1b and 2c).
FHL tenosynovitis is usually seen in danc- ers and long-distance runners (3). Associ- ated symptoms can be felt anywhere along the length of the FHL from the posterior leg to the plantar foot and the hallux. Misdiag-
Corresponding author Marco A. Cimmino Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa
Viale Benedetto XV, 6 16132 Genoa, Italy E-mail: cimmino@unige.it Reumatismo, 2017; 69 (4): 189-190
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der. Pain was not elicited at extension and
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der. Pain was not elicited at extension and flexion of the great toe.
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flexion of the great toe.
An MRI exam was performed on a dedi
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An MRI exam was performed on a dedi cated 0.3 T unit (Oscan, Esaote, Genova,
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cated 0.3 T unit (Oscan, Esaote, Genova,
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seronegative spondyloarthritides (2). Alter
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seronegative spondyloarthritides (2). Alter natively, pain could be caused by involve
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natively, pain could be caused by involve-
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- ment of a different structure. We report a
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ment of a different structure. We report a patient treated for one year for plantar fas
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patient treated for one year for plantar fas-
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- ciitis, who was affected by flexor hallucis
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ciitis, who was affected by flexor hallucis longus (FHL) tenosynovitis diagnosed by
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longus (FHL) tenosynovitis diagnosed by magnetic resonance imaging (MRI).
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magnetic resonance imaging (MRI).
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A 50-year-old man presented with a one-
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A 50-year-old man presented with a one-
year history of severe pain on the medial
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year history of severe pain on the medial
Italy) with T1-weighted spin echo, STIR
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Italy) with T1-weighted spin echo, STIR and 3DT1 sequences on the three planes of
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and 3DT1 sequences on the three planes of the space. Increased thickness (6 mm) of
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the space. Increased thickness (6 mm) of the medial band of the plantar fascia with
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the medial band of the plantar fascia with out signs of inflammation was seen in the
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out signs of inflammation was seen in the sagittal plane. It was associated with slight
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sagittal plane. It was associated with slight was more intense on the right side. The cal
use
was more intense on the right side. The cal
use
caneal insertion of the fascia was not ten
use
caneal insertion of the fascia was not ten der. Pain was not elicited at extension and
use
der. Pain was not elicited at extension and flexion of the great toe.
use
flexion of the great toe.
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Reumatismo, 2017; 69 (4): 189-190
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Reumatismo, 2017; 69 (4): 189-190 Reumatismo, 2017; 69 (4): 189-190
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Reumatismo, 2017; 69 (4): 189-190
was more intense on the right side. The cal
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was more intense on the right side. The cal
RADIOLOGICAL
VIGNETTE N. Romano, A. Fischetti, V. Prono, et al.
RADIOLOGICAL VIGNETTE
190 Reumatismo 4/2017
nosis of this condition as plantar fasciitis is made in 55.5% of patients (4). Conserva- tive treatment is effective in the majority of patients, but surgery is necessary in about one third (3, 4).
Another possible differential diagnosis is os trigonum syndrome (5), a posterior im- pingement syndrome of the ankle, which presents with chronic pain. It is also fre- quent in dancers as result of an overuse syndrome. Os trigonum originates from the failure of a secondary ossification center to fuse to the lateral tubercle pos- terior process of the talus. When the FLH tendon travels between the medial and the lateral tubercle of the talar posterior process, compression of the tendon by the os trigonum with associated tenosynovi- tis can occur. Os trigonum was not pres- Figure 1 - Sagittal image of a STIR sequence of the foot showing the flexor hallucis longus tendon (arrows) at baseline (a) and five weeks after a local glucocorticoid injection (b). Note the fluid effusion around the tendon, which disappeared at follow up.
Figure 2 - Axial image of a STIR sequence of the foot showing the flexor hallucis longus ten- don (arrow) at baseline (b) and five weeks after a local glucocorticoid injection (c). The drawing (a) shows the anatomical landmarks.
ent in our patient, however. In conclusion, FHL tenosynovitis was suspected in our patient at physical examination and con- firmed by MRI. The diagnosis could also have been obtained by ultrasonography, which is cheaper and widely available.
However, we had the opportunity to use a dedicated MRI machine in our outpatient clinic, which provided diagnostic aid in real time. MRI has the advantage of eval- uating simultaneously the bone, synovial membrane and soft tissues.
Competing interests: There are no com- peting interests regarding this paper.
n REFERENCES
1. Pollack A, Britt H. Plantar fasciitis in Austra- lian general practice. Austr Fam Pract. 2015;
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2. Ansell RC, Shuto T, Busquets-Perez N, et al.
The role of biomechanical factors in ankylos- ing spondylitis: the patient’s perspective. Reu- matismo. 2015; 67: 91-6.
3. Funasaki H, Hayashi H, Sakamoto K, et al.
Arthroscopic release of flexor hallucis lon- gus tendon sheath in female ballet dancers:
dynamic pathology, surgical technique, and return to dancing performance. Arthros Techn.
2015; 4: e769-74.
4. Michelson J, Dunn L. Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment. Foot Ankle Int. 2015; 26: 291-303.
5. Song AJ, Del Giudice M, Lazarus ML, et al.
Radiologic case study. Os trigonum syndrome.
Orthopedics 2013; 36: 63-8.
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nosis of this condition as plantar fasciitis is
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nosis of this condition as plantar fasciitis is made in 55.5% of patients (4). Conserva
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made in 55.5% of patients (4). Conserva tive treatment is effective in the majority of
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tive treatment is effective in the majority of
- Axial image of a STIR sequence of the foot showing the flexor hallucis longus ten
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- Axial image of a STIR sequence of the foot showing the flexor hallucis longus ten don (arrow) at baseline (b) and five weeks after a local glucocorticoid injection (c). The drawing
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don (arrow) at baseline (b) and five weeks after a local glucocorticoid injection (c). The drawing (a) shows the anatomical landmarks.
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(a) shows the anatomical landmarks.
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use only only only
Competing interests:
only
Competing interests:
peting interests regarding this paper.
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peting interests regarding this paper.
